However, long-term DAPT lost its advantage over a short-term strategy among noncomplex PCI patients (adjusted HR 1.01, 95% CI 0.75-1.35, P for interaction=0.01), according to Alaide Chieffo, MD, of San Raffaele Scientific Institute in Italy, and colleagues in their study online in the Journal of the American College of Cardiology.

"Alongside other established clinical risk factors, procedural complexity is an important parameter to take into account in tailoring upfront duration of DAPT," the researchers said. "The benefits of prolonged DAPT appeared to be uniform across complex PCI components, DES generations, and clinical presentation."

The more complex the procedure, the greater the magnitude of benefit seen with prolonged DAPT, the investigators added.

Nonetheless, long-term DAPT was tied to more major bleeding in both groups, irrespective of procedural complexity.

"On the basis of these data and those from other studies, it seems reasonable to consider shorter-duration DAPT in those with low clinical risk (e.g., nonacute coronary syndrome, nondiabetic, de novo lesions) and low angiographic procedural risks," according to Robert C. Welsh, MD, of the Mazankowski Alberta Heart Institute in Canada, and Eric D. Peterson, MD, of Duke University Medical Center in Durham, N.C., writing in an accompanying editorial.

The editorialists suggested that clinicians "determine whether the benefits of longer-duration DAPT on MACE are worth the slight, but real, increased risk for bleeding.

"Although these decisions may be complex, such individualization appears required to optimize patient outcomes."

There were 9,577 individuals included in the Chieffo et al study, 17.5% of whom underwent complex PCI. All had been enrolled in one of six studies and randomized to DAPT for 3 to 6 months or more than 1 year; median follow-up was 392 days.

Most patients (85%) received new-generation DES.

Those undergoing complex PCI were more likely to have adverse events (adjusted HR 1.98, 95% CI 1.50-2.60) than those receiving noncomplex PCI.

"Our results have to be considered hypothesis-generating, as this is a non-prespecified, post-hoc analysis from randomized controlled trials that were not designed to test the benefit of long-term DAPT according to procedural complexity," the team noted.

"The study is ultimately a synthesis of retrospective data and thus can only analyze what was collected," Welsh and Peterson said. "Therefore, the investigators' definition of 'procedural complexity' was constrained to those features collected consistently across each trial. Thus, the investigators did not consider such angiographic risk factors as saphenous vein grafts, small-diameter vessels (stent diameter <3 mm), or final stent apposition."

Additionally, the investigators predefined their complexity definition, rather than prospectively deriving it on the basis of their analysis, the editorialists pointed out. "As such, chronic total occlusion [CTO] was considered a component of 'complex PCI,' even though the analysis found that CTO intervention (n=182) actually had similar MACE risk, regardless of the duration of DAPT.

"One could debate whether the reductions in MACE gained by longer-term DAPT, even among those with complex PCI, were worth it after accounting for their higher risks for major bleeding. This debate is particularly relevant because overall mortality rates were similar regardless of the duration of DAPT among those with complex or noncomplex PCI."

The field of intervention continues to evolve, making the generalization of prior studies to contemporary practice suspect, Welsh and Peterson wrote, asking: "Are the risks of stent thrombosis or MACE on the basis of trials using first- and second-generation stents relevant to the latest generation stents (e.g., bioabsorbable, lower profiles)? Similarly, do the benefits (and risks) of DAPT based predominately on clopidogrel generalize to those treated with ticagrelor [Brilinta]?"

Chieffo declared no relevant conflicts of interest. His coauthors reported several financial relationships with industry.

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